INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 23, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TrueNorth Wellness Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of five personnel records, the facility failed to ensure there was a mechanism to collect feedback on completed training in all five records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
9/28/2021 Facility Director told Clinical Supervisor to remind all staff to complete the form we have for evaluation of training each time they submit a training certificate to us. On 9/30/2021 Clinical Supervisor reminded all staff at the weekly staff meeting to complete the evaluation of training form for each training they attend. A blank copy of the form was given to each staff. Clinical Supervisor will review certificates of training turned in by staff weekly and obtain completed form from staff. Facility Director will inform Clinical Supervisor in the event a staff does not include this form when staff give certificates to Director. Clinical Supervisor will follow up with all staff if this occurs. Clinical Supervisor will review during weekly staff meetings and inform staff to turn in any missing certificates along with the evaluation form. Clinical Supervisor has created individual development plans to address all areas that we received citations for. Clinical Supervisor will review these plans with staff every 90 days and further disciplinary action will be taken as needed. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee #5 was hired as a counselor on September 5, 2017 and was still current in that position at the time of the inspection. Employee #5 was reported to have 8 hours per week devoted to their 8 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 8/37.5=.2133(FTE); 8/.2133 =37.5058, which equals to a client/counselor ratio of 37:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 has since discharged several clients, bringing his caseload of weekly seen clients to 7 and his less than twice per month clients to 3, thus making his client/staff ratio 32.86. Clinical Supervisor and Facility Director will restrict the number of new clients employee #5 is assigned to 7 weekly. This employee may move more clients to be seen less than twice per month. Clinical Supervisor will monitor this employees case load to ensure he is discharging clients before he takes on any new ones. This was corrected on 11/22/2021. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of seven client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one client record reviewed.
Client #1 was admitted on December 29, 2020 and was current at the time of the inspection. An informed and voluntary consent signed and dated by a witness on December 29, 2020 did not include the name of the person, agency or organization to whom disclosure may be made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Proper release of information form was reviewed with front office staff. This form was actually waiting in the client record for the client to come in to sign before any records were released. Facility Director spoke with Customer Engagement Manager who supervises the front office staff on 11/19/2021 to review proper elements of a release of information to include what is being disclosed. Front office staff will fill in what is being released and her manager will check her services weekly so this does not recur. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated signature of the client in one record reviewed.
Client #1 was admitted on December 29, 2020 and was current at the time of the inspection. An informed and voluntary consent signed and dated by a witness on December 29, 2020 did not include a dated client signature.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Proper release of information form was reviewed with front office staff. This form was actually waiting in the client record for the client to come in to sign before any records were released. Facility Director spoke with Customer Engagement Manager who supervises the front office staff on 11/19/2021 to review proper elements of a release of information to include the client signature and date signed. Front office staff will fill in what is being released and her manager will check her services weekly so this does not recur. No information will be released without the client's signature. Staff supervisor will provide additional supervision regarding collecting the client' signature and date signed, check her services weekly to ensure this does not recur. |